Inspection on 04/06/08 for Treelands Care Home

This inspection was carried out on 4th June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Treelands Care Home 12/06/09

Treelands Care Home 26/06/07

Treelands Care Home 26/04/06

Treelands Care Home 24/11/05

Treelands Care Home 20/06/05

Treelands Care Home 28/09/04

Treelands Care Home 11/05/04

Treelands Care Home 16/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Treelands Care Home Greenhurst Crescent Oldham OL8 2QQ Lead Inspector Sandra Buckley Unannounced Inspection 4th June 2008 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treelands Care Home Address Greenhurst Crescent Oldham OL8 2QQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 626 7173 0161 628 9793 treelands@schealthcare.co.uk Southern Cross Healthcare (Kent) Ltd Mrs Pauline Smithstone Care Home 80 Category(ies) of Dementia (40), Dementia - over 65 years of age registration, with number (40), Mental disorder, excluding learning of places disability or dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (20), Old age, not falling within any other category (40), Physical disability (40), Physical disability over 65 years of age (40), Sensory impairment (4) Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No Service User to be admitted into the home who is under 55 years of age. The manager must be supernumerary at all times. Date of last inspection 26th June 2007 Brief Description of the Service: Treelands is owned and managed by Southern Cross Health Care Services Limited, which is a private company with a number of other homes in the area. Treelands is a purpose built home, located in the Fitton Hill area of Oldham. Treelands provides general nursing and personal care for up to 40 service users, specialist dementia care for a further 40 service users and care for service users with other mental health needs. The home does not provide care for service users under the age of 55 years. Accommodation is provided over two floors, the first floor being accessible by a lift. Each floor is divided into two units, which are separately equipped with bath and shower rooms, treatment rooms and lounge/dining rooms. The general nursing unit occupies the ground and first floors on one side of the building, whilst service users with mental health needs occupy the ground and first floors on the other side. All bedrooms provide en-suite facilities. Separate self-contained, secure gardens are accessible from each unit. The current weekly fees range from £360.00 to £516 plus contributions from Primary Care Trust if nursing care is required and dependent on the package. Further details regarding fees are available from the manager. No additional charges are currently made. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, including observing care practices and talking to people in the home. The manager, relatives, residents and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. The CSCI requires the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. The manager had completed this in full and comparisons were made with this document at the time of inspection. On this inspection the outcomes for people in the home did reflect that indicated by the manager in the AQAA, especially in relation to daily life, personal care and protection. However, the manager had recognised how improvements could be made and was taking steps to address the issues. There had been five complaints since the last inspection, all of which had been appropriately addressed by the manager. Three allegations in connection with the protection of vulnerable adults had been investigated since the previous key inspection. In all cases, the home followed the appropriate inter-agency procedures and co-operated fully with the independent investigators. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There have been a number of improvements to the environment since the last inspection that include: redecoration, some new carpets in bedrooms and dining rooms and kitchen refurbishments on individual units. The manager has also introduced weekly doctors’ rounds to monitor people’s needs and any adjustments to medication. The quality of food and choices offered have improved since the last inspection and an additional chef has been employed. One person said “I really like it here; what I enjoy about it is the choice of food which suits me fine, I am a vegetarian but still have plenty of choice”. One member of staff is now a trained moving and handling facilitator to ensure staff receive training and refresher courses on a regular basis. A new key worker system is in operation with people’s key worker’s photograph being put up in people’s bedrooms so they and their relatives know who to discuss any issues with. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 7 A dementia library is a available for staff and visitors to access. The manager reported that some relatives had also chosen to take part in dementia training to provide a deeper understanding of the illness. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People’s needs were assessed prior to going into the home, ensuring their needs could be met. EVIDENCE: The statement of purpose and service user guide can be found in the reception area of the home, together with the last inspection report for prospective service users to view. Four case files were examined, one from each unit. All were found to have a detailed assessment of the service user’s needs that reflected their emotional, physical, and social needs. Social interests, preferred activities and hobbies were also included in the assessment. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 10 In some instances, additional assessment had been sought from other professionals who had been involved with care delivery and assessment, for example, Community Psychiatric Nurses and Dieticians. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff training in line with people’s needs ensured people’s physical and emotional needs were meet in a supportive and respectful manner. EVIDENCE: The home provides nursing care and support across a range of needs that includes people with different stages of dementia. The Annual Quality Assurance Assessment (AQAA) stated that improvements made since the last inspection has included weekly Doctors’ rounds with the manager, which we saw taking place whilst we were at the home. A care plan was in place for all assessed needs identified prior to people entering the home. These also include dementia care plans linked to specialised assessments. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 12 Risk assessments were in place and the nutritional needs of people were monitored. People were weighed regularly and the manager undertakes monthly checks to ensure any weight loss is identified and a care plan implemented. Good instructions were in place for staff on how to encourage people to eat and dealing with challenging behaviour. Care plan review dates were recorded and a record of professional visits was completed. Daily notes were detailed and reflected the care given. People’s social interests and sexuality were recorded, for example, one person likes to wear perfume, make-up and earrings. We observed that this request had been carried out. Relative interviews were positive about the home, saying “I am very happy with the care, staff always keep me informed”, “My wife always looks clean and tidy” and “sometimes my wife refuses care and staff just wait and ask again later”. Another said “My husband has difficulty eating and they gave supplement drinks to ensure that he does not lose weight” also “staff always attend to personal hygiene well”. Service users said, “staff are very nice and helpful”. A member of staff had trained as a moving and handling facilitator to ensure that staff receive training in moving and handling at the time of their induction. Equipment in the home included standing hoist, hoist, swing chair, banana boards and moving belts. The manager monitors accidents in the home in order to identify patterns, times and areas where accidents have occurred. There was documented evidence of staff training in Palliative Care, Dementia Awareness and Health and Safety. Medication records were examined and were recorded well, with a procedure in place for checking medication upon receipt from the pharmacist. Each unit has a medication audit every month and the manager undertakes spot drug takes. Controlled drugs were stored appropriately. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Mealtime choices and activities had improved and lifestyle preferences of people are respected. EVIDENCE: The last inspection identified that most negative comments were in relation to meals and service. Menus have been fully reviewed and two chefs have now been recruited. We dined with people in the home and discussed the quality of food and choices available to them and made observations of the dining process. People’s comments included: “Food is very good, you get too much”, “Staff are very helpful” and “I have not been here very long, but it is OK, not much to do, would rather stay in my room; there is no problem with that”. Another person said “I am a vegetarian but still have a lot of choice, also the activity person does glass painting with us which I have put on to my window. I like to help with household chores like setting tables and washing and drying the dishes”. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 14 Menus are on display in large print, they were also on the information board of the home for the relatives to view. The main meal of the day is served at teatime and staff were observed helping people in a sensitive manner. There was a choice of a hot meal both at lunch and tea time, fruit juice was on each table and there was a choice of tea or coffee. Tables were set in an attractive manner. Coffee is available for relatives in reception, together with a display of people’s art and craft work. The Annual Quality Assurance Assessment stated improvements have been made since the last inspection, which included recruiting and additional activities person and acquiring the use of a mini bus. One relative said “Staff do really well with social events. People have a notice on their bedroom doors when it is their Birthday and a cake is provided”. A record of activities and participants was also maintained. Photos of staff are on the wall in reception and the introduction of a new key worker for system will have staff pictures on bedroom doors for relatives and people to refer to if they have any problems. People felt that daily life was flexible saying, “I like to go to bed at 6:30pm and watch my own TV in comfort”. People’s preferences were recorded in care planning, an example being “likes to get up at 5am always an early riser”. Several people had a map of life completed that improves the ability of staff to provide individualised activities. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are protected from abuse or exploitation by the home’s policies and practices. EVIDENCE: A complaints procedure is in place, which has been found to be appropriate in the past and was not assessed at this visit. A written copy of the procedure was available in the foyer. The log of complaints maintained in the home was looked at and presented as being appropriately maintained. Since the last key inspection, some complaints had been received by the Commission for Social Care Inspection and were passed back to the provider to deal with. Information subsequently received indicated that these had been appropriately dealt with. One service user who was spoken to said “I have no complaints or concerns and would see the manager if I weren’t happy”. Observation of interactions between staff and service users presented as relaxed. There was documentary evidence that staff had received training in connection with safeguarding vulnerable adults. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 16 Three allegations in connection with the protection of vulnerable adults had been investigated since the previous key inspection. In all cases, the home followed the appropriate inter-agency procedures and co-operated fully with the independent investigators. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People live in a safe and well-maintained environment that they have personalised and are provided with equipment to promote their independence. EVIDENCE: Appropriate equipment is provided for moving and handling, toileting and bathing in a safe environment. The Annual Quality Assurance Assessment stated that improvements had been made and gave examples of new kitchens and flooring, and new carpets in some bedrooms and dining rooms throughout the home. Plans for the future include an increase in domestic hours and plans for a sensory garden area, raised flowerbeds and conservatory. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 18 All communal areas and a selection of bedrooms were inspected on each unit. Bedroom doors had photos and personal items for recognition. Bathroom and toilet signage was also in picture format. People and their relatives had chosen to personalise their rooms providing a homely appearance. One person had chosen to bring in their own bed. At the time of inspection ELM unit was undergoing redecoration. The environment was clean, tidy and free from odour. A maintenance person is employed full-time to maintain safety and standards in the home. A colour code traffic light system was placed on doors to alert new or agency staff to the dependence levels of the person in the room. Red for full assistance, green for mobile and yellow for minimal assistance. Wardrobe doors also had a mobility assessment and risk care plan to provide additional information to staff while providing care for people in their rooms. One person and their relative said, “I have no problems, I am very happy with this room”. A twinkle room is also available for quiet relaxation. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Recruitment and vetting procedures are effectively applied to minimise the risk to service users of inappropriate staff being employed. The numbers and skill mix of staff on duty promotes the independence and well being of service users. EVIDENCE: Staffing levels were reported by the manager as being predominantly supplied in two shifts. The day shift between 08:00 and 20:00, and the night shift from 20:00 to 08:00. During the day three carers plus one nurse are provided on three units, with three carers provided for the remaining unit, which does not provide nursing care. Additionally, a ‘twilight’ staff member has been added to two of the ‘nursing’ units between 18:00 and 22:00. The staff rota for the week beginning 25th May 2008 was looked at and provided evidence that these levels were maintained. Staffing levels are complemented by auxiliary staff in the kitchen who also undertake the domestic work. There was good documentary evidence that staff had access to a range of appropriate training, including palliative care, dementia awareness, protection of vulnerable adults and various health and safety related courses. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 20 The manager reported that the ‘care’ staff included 14 qualified nurses and 28 other carers. Of those 28, five were reported as having NVQ II and nine as having NVQ III. At the time of the site visit not all certificates were available to verify these qualifications as, it was reported by the manager and a staff member, they had been sent to Head Quarters to enable pay rates to be adjusted. Staff at interview, confirmed the availability and attendance at training. A sample of staff files was looked at in connection with the recruitment and vetting practises at Treelands. These were predominantly well maintained, giving good evidence that appropriate checks are undertaken before a new member of staff starts work. This process would be improved by the inclusion of a written record of the exploration of gaps in employment history or anomalies with references. Service users who were spoken to were positive about the staff team. For example, one person said ‘Staff are very nice and helpful’ and another said, “[the] carers are very good.” Also “I have never seen staff being disrespectful.” Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager is competent to run the home, use the quality audit systems and implement the health and safety procedures for the benefit of service users and staff. EVIDENCE: The qualifications and experience of the manager have been confirmed at previous inspections and were not looked at in detail at this site visit. However, she continued to present as competent and maintaining an up to date knowledge of the conditions affecting old age. One visitor who was spoken to lives abroad, and was pleased that she still gets good communication from the manager via e-mail. This visitor was very satisfied and said, “[I] couldn’t wish for a better place”. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 22 There was documentary evidence that the organisation sends out regular surveys to a random selection of stakeholders. There was also documentary evidence that the manager took action when an issue was identified. There was no specific recent analysis of returned surveys. The Operation Manager reported that she was aware that the company had recruited external quality audit consultants who were working their way round the different homes in the organisation. This process will include an independent analysis of the results of the surveys and the creation of an action plan to address any issues identified. The manager and another member of staff confirmed that surveys from the Commission for Social Care Inspection had been distributed, although the inspectors had received none at the time of the site visit. A selection of records relating to money held by Treelands on behalf of service users was looked at. The records presented as being appropriately maintained to safeguard the interests of the service users. One example was seen where one receipt had been obtained for a selection of toiletries for several service users. The process would be even better if there was a specific record of which toiletries each service user had received, rather than only the proportion of the total amount charged to them. At previous inspections the home has been found to have appropriate procedures to address health and safety issues. A range of documentation relating to both routine maintenance and regular testing of equipment was available to be looked at. A small sample was chosen at random and found to be appropriately maintained. No issues indicating that health and safety are compromised was identified from a tour of the building or discussion with staff and service users. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP29 OP35 Good Practice Recommendations Gaps and anomalies in application forms for new staff should be recorded to provide evidence of these issues being discussed verbally. Receipts for expenditure of service users’ monies should be obtained individually, where possible. Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Treelands Care Home DS0000042440.V365478.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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